Brief Issue Description
CMS is introducing a new RESTRICTED-BENEFIT-CODE (ELG097) value to identify individuals dually eligible for Medicare/Medicaid who are enrolled in the Medicare Part B immunosuppressive drug (ID) benefit coverage.
Background Discussion
In December 2020, the Consolidated Appropriations Act (CAA) of 2021[1] was signed into law. It included a provision in Section 402 extending Medicare Part B coverage of immunosuppressive drugs for individuals who were eligible for Medicare solely because they had End-Stage Renal Disease (ESRD) that resulted in a kidney transplant covered by Medicare Part A in a Medicare-certified facility and whose 36 months of Medicare Part B coverage of immunosuppressive drugs had run out. This new benefit covers only immunosuppressive drugs and is referred to as the Medicare Part B-ID benefit. Before the CAA of 2021, individuals who were eligible for Medicare solely because of ESRD that resulted in a kidney transplant covered by Medicare Part A in a Medicare-certified facility were only eligible for Medicare Part B coverage of immunosuppressive drugs for 36 months after the month of the transplant.
Context
Individuals are only eligible for Medicare Part B-ID benefit coverage if they do not have any other private insurance, Medicaid, or other public coverage of immunosuppressive drugs. As of the time of this publication, all states cover immunosuppressive drugs for beneficiaries with full Medicaid benefits. Therefore, the Medicare Part B-ID benefit only applies to persons with partial Medicare-Medicaid dual eligibility enrolled in a Medicare Savings Program (MSP). These beneficiaries are eligible for Medicaid to pay the Medicare premium and, if/when applicable, Medicare cost-sharing for the Part B-ID benefit[2]. These beneficiaries must be reported to T-MSIS.
Challenge
Because this is a new benefit, there is currently no way to identify it in T-MSIS.
Technical Instructions
CMS is introducing a new RESTRICTED-BENEFIT-CODE value ‘G’ to identify that an “Individual is eligible for Medicaid but only entitled to restricted benefits based on Medicare dual-eligibility status Medicare Part B-ID ESRD Benefit.” The value was added to the list of valid values on September 16, 2022 and can be used for ELIGIBILITY-DETERMINANTS-ELIGIBLE-ELG00005 segments with effective dates greater than or equal to January 1, 2023[3].
When a beneficiary that is partial dual-eligible (MSP-only) beneficiary loses Medicare entitlement that was based on ESRD 36 months after the month of a successful kidney transplant and converts to an MSP Part B-ID after enrolling in Part B-ID, the state will need to take the following steps:
- End-date the beneficiary’s existing ELIGIBILITY-DETERMINANTS record segment (i.e., the segment containing RESTRICTED-BENEFIT-CODE “1”or “3”), and
- Add a new ELIGIBILITY-DETERMINANTS record segment that contains the new RESTRICTED-BENEFIT-CODE value of ‘G’ that identifies the beneficiary’s coverage as MSP Part B-ID.
[1] H.R.133 - Consolidated Appropriations Act, 2021
[2] This information is subject to state policy changes. An individual would be eligible for Medicare Part B-ID benefit coverage if the state’s Medicaid program did not include coverage of immunosuppressive drugs.
[3] For the most up to date T-MSIS data element definitions, valid values, and other T-MSIS data dictionary artifacts, state T-MSIS teams should refer to the Data Guide available on the Operations Dashboard (OD) via the CMS.gov Enterprise Portal. Users without access to the OD should refer to the publicly available Data Dictionary artifacts published on Medicaid.gov. CMS publishes major version updates of the Data Dictionary and associated artifacts to Medicaid.gov. Minor version updates are published to the Data Guide on a more frequent basis. In the future, CMS plans to make the Data Guide publicly available.
[4] CMS Guidance: Reporting Expectations for Dual-Eligible Beneficiaries, Updated